“A leading association of bioethicists has come squarely behind the idea of mandated vaccination. A statement issued by the Association of Bioethics Program Directors (ABPD) declared that ‘To protect the health, safety and future prosperity of humankind, mandated vaccination is now necessary.’ It was supported by two-thirds of ABPD members.”
This story from BioEdge, which also included an explanatory note by Art Caplan, one of America’s most-quoted bioethicists, crystalized my increasing discontent with the stance taken by some senior – or should I say elderly – figures in the field of bioethics and medical law.
After decades of resisting compulsion and emphasising the importance of free and informed consent to medical interventions, it seems that these principles can now be junked under the conditions of a pandemic.
Let me be clear. This is not an anti-vaxx post. I have served on a UK government committee supporting our vaccine roll-out; I am convinced by the evidence of benefit for most people; and I have, at the age of 71, taken my turn in the lines to get my shots. When I am invited for a booster, I shall turn up, although at my convenience rather than as a matter of urgency, because waning is not a cliff edge.
I am, however, deeply sceptical about the idea of compulsory vaccination in the current state of knowledge. It may be a difficult moment for bioethicists to stand against the tide – but if bioethicists are not prepared to get going when the going gets tough, what is the point of the field? Are we obliged to agree with Nietzsche that philosophy is “most often a desire of the heart that has been filtered and made abstract that [philosophers] defend with reasons they have sought after the fact”?
Is the stance of some of our seniors really an expression of their personal risk-aversion rather than one of ethical principle?
Bodily autonomy matters.
After World War II, the Allied Powers were slow to accept that the Nuremberg Code of research ethics for human experimentation applied to them as well. But the principle of “respect for persons” in the 1979 Belmont Report is unequivocal. While this was developed in the context of research, it was elaborated in the work of Tom Beauchamp and James Childress as a fundamental principle for all medical interventions.
Only in the most limited circumstances, where patients lack the capacity for self-determination, can it be overridden –and then only with the greatest care and sensitivity. In many countries, it requires the intervention of a court of law or, at the very least, the exercise of medical power within a framework of legal accountability.
The bioethicists in the ABPD assert that the Covid-19 pandemic is a public health emergency that justifies overwriting the foundational texts of the field. This is argued on empirical rather than moral grounds. In some respects, this is not surprising: critics of principlism have long observed that it elevates autonomy over justice, individuals over communities.
But it is the precisely the defence of unpopular individual positions that makes bioethics or human rights law important.
On empirical grounds, SARS-COV-2 does not meet the criteria for eradication put forward by Donald Henderson, the US doctor responsible for eliminating smallpox. That would have been a strong argument for compulsion. But the vaccines do not confer sterilising immunity, which means that they reduce the frequency and severity of infection but do not eliminate it. The virus can circulate among the vaccinated just as among the unvaccinated. In due course the unvaccinated will become infected, derive immunity from that, and become less likely to transmit the virus.
In a country with a nationalised health system, there might be an argument for mandates to reduce the collective demand, but this does not apply in the US. The communitarian arguments are equally weak: my vaccination protects me but only offers a limited benefit to you.
There may be circumstances in which a mandate could be justified, where health and social care workers are looking after people who cannot be vaccinated or will only develop low levels of antibodies. This does not eliminate the risk, but it would mitigate it. However, there are very few such people.
Otherwise the vaccines protect those who choose to accept them. If I am an 80+ bioethicist without an immunosuppressive condition, the vaccine protects me, regardless of whether or not my visiting nurse has been vaccinated. I do not see that I then have the right to demand that he or she must also have a shot. By all means encourage this, but do not start firing people or imposing civil disabilities upon them, simply because they happen to make decisions we do not agree with. Bioethics has always insisted on their right to do this.
Bioethicists, and their fellow-travellers in law, have been leaders since the 1970s in the movement to have the rights of patients recognized in health care. They are an important part of the pushback against medical paternalism.
Unhappily, half a century of progress has been binned in the course of the pandemic as we are told that we must be ruled by biomedical science rather than engage in dialogue with it or hold it to account before the law. Many leaders are now abandoning the fight precisely when their voices are most needed.
As MercatorNet’s editor observed when inviting this contribution, it is a Marxist position – but Groucho rather than Karl: “Those are my principles, and if you don’t like them… well, I have others.” A bioethics program that is not prepared to reach unpopular conclusions is not one worth having.